Ii297

ends can be cut or can be left long and held for traction until the next suture has been placed.

When the cut edges of the linea alba can be approximated only with tension, one can close with interrupted far-near sutures. These penetrate the rectus sheath about 3 cm lateral to the cut edge, pass beneath it through the anterior fibers of the rectus muscle to cross the wound and emerge through the anterior rectus sheath 0.5 cm from its cut edge on the other side, cross over the wound to penetrate the original side of the anterior sheath from superficial to deep at a point 0.5 cm lateral to its cut edge, recross the wound, and pass through the superficial rectus fibers beneath the rectus sheath of the other side to emerge about 3 cm lateral to the edges ( Fig. 21-21A ). When these sutures are pulled taut and tied, any tension is distributed to four points instead of only two and a stronger closure results, although more time is consumed in closing the incision.

This type of suturing is also helpful when there is difficulty in approximating the cut edges of the peritoneum. In such a subject, a few peritoneal sutures are placed and then covered over with near-far sutures placed in the rectus sheath as just described. This more closely approximates the portion of the wound just above so that more peritoneal sutures can be placed above to be covered in turn by the rectus sheath. Progressing in this way, a peritoneal layer that previously seemed impossible to close can often be approximated satisfactorily. In some instances, suturing of the rectus sheath alone will approximate the peritoneal edges without the necessity of the edges being sutured separately, but for most patients, a separate peritoneal closure would be preferred. The same type of technique can be used to close the peritoneum and linea alba with one row of stainless-steel wire or 0-0 or No. 1 polypropylene sutures (see Fig. 21-21 ). This is a particularly valuable method when the peritoneal layer cannot be separated from the overlying layers.

When closing either the peritoneal or linea alba layer, the suturing should begin at the lower end of the incision and progress upward toward the xiphoid. Sutures should be placed about 1 cm apart and, at the conclusion of the closure, there should be no space between them wide enough to admit the tip of a little finger.

• After the linea alba has been firmly closed, the subcutaneous fat and fascia are approximated with a row of fine sutures. For this layer, one may use 4-0 plain catgut, 3-0 or 4-0 synthetic absorbable sutures, or 4-0 silk, placed as simple over-and-over interrupted sutures. Silk should never be used in possibly contaminated wounds.

• The skin is closed with 3-0 or 4-0 nylon or 4-0 silk by one of the methods described under skin sutures. Continuous or interrupted sutures are used for this layer. Stainless-steel staples also can be used. If the wound is suspected of possible contamination, one should use interrupted sutures. These sutures are removed on the fifth to seventh postoperative day.

Figure 21-21 A, Scheme of interrupted far-near suture used when linea alba can be approximated only with tension. B, Same type of suture used to close the linea alba and peritoneum. (Modified from Maingot, R.: Abdominal Operations, 2nd ed. New York, Appleton-Century-Crofts, 1948, with permission.)

Abdominal Sagittal
'Peri, tone lAm

Figure 21-22 Upper abdominal midline incision, enlargement of the operative field resulting from the removal of the xiphoid process and the upward extension of the peritoneal opening made possible by this procedure. (From photographs taken at the operation.) (From Saint, J.H., and Braslow, L.E.: Removal of the xiphoid process as an aid in operations on the upper abdomen. Surgery, 33:361, 1953, with permission.)

Figure 21-23 Diagrams in sagittal plane showing upper midline incision before (A) and after (B) removal of the xiphoid process. Note in B the upward extension of the peritoneal incision and the resultant decrease in anteroposterior depth of the wound. (From Saint, J.H., and Braslow, L.E.: Removal of the xiphoid process as an aid in operations on the upper abdomen. Surgery, 33:361, 1953, with permission.)

Figure 21-24 Method of extending an upper midline incision. A, Lateral extension (dotted line) of conventional upper midline incision. B, Exposure of costal arch; the cartilage has been scraped bare around its entire circumference. Incisions either to reflect or to resect the costal arch are indicated.

Pararectus Approach

Figure 21-25 Garlock combined abdominothoracic approach to lower end of esophagus and cardia of stomach. Inset top left, A 12.5-cm left pararectus incision continues from the costal arch between the eighth and ninth ribs as far as the vertebral border of the scapula. A, The costal arch is divided along the line of incision between the eight and ninth ribs. B, The incision is swung upward and outward in the intercostal space between the eighth and ninth ribs. (From Garlock, J.H.: Combined abdominothoracic approach for carcinoma of cardia and lower esophagus. Surg. Gynecol. Obstet, 83:737, 1946. By permission of Surgery, Gynecology and Obstetrics.)

9th Rib Arch

Figure 21-26 Garlock combined abdominothoracic incision. A, Diaphragm divided in direction of skin wound from its peripheral attachment to the esophageal hiatus. B, Rib edges retracted and excellent exposure of gastric cardia and lower esophagus obtained. (From Garlock, J.H.: Combined abdominothoracic approach for carcinoma of cardia and lower esophagus. Surg. Gynecol. Obstet., 83:737,1946. By permission of Surgery Gynecology and Obstetrics.)

Figure 21-27 Large figure on left represents exposure for gastroesophageal resection or for repair of hiatal hernia. (From Miller, H.I.: Sternum-splitting incision for upper abdominal surgery. Arch. Surg., 65:876, 1952. Copyright 1952, American Medical Association.)

Figure 21-28 T-shaped extension of upper midline incision. A, Transection of rectus muscle over two fingers placed deep into the muscle and anterior to the posterior sheath. B, Fibers of external oblique aponeurosis severed upward and downward at attachment to anterior rectus sheath; oblique muscles split in direction of fibers, preserving innervation; and lateral division over fingers of posterior rectus sheath and peritoneum.

Extraperitoneally

Figure 21-33 Technique of extending a paramedian incision by dividing the rectus muscle and the costal cartilages extraperitoneally. A, Reflection as a flap of the upper segment of the divided rectus muscle with its overlying subcutaneous tissue and skin. B, Division of chondral arch and cartilages of three ribs; vertical division of the posterior rectus sheath and lateral division of same indicated. C, Exposure through paramedian incision extended laterally.

Figure 21-33 Technique of extending a paramedian incision by dividing the rectus muscle and the costal cartilages extraperitoneally. A, Reflection as a flap of the upper segment of the divided rectus muscle with its overlying subcutaneous tissue and skin. B, Division of chondral arch and cartilages of three ribs; vertical division of the posterior rectus sheath and lateral division of same indicated. C, Exposure through paramedian incision extended laterally.

Anterior» rectus ehealh

Rectus Abdominis Incision

Figure 21-34 Upper vertical transrectus (muscle-split) incision. This wound may be closed in the manner depicted, with a series of closely applied interrupted sutures. There is no need to insert any special sutures to draw the muscle edges themselves together, because the muscle margins fall together when the anterior sheath of the rectus muscle is approximated.

Figure 21-35 Technique of pararectus incision in the lower abdomen (Kammerer-Battle). A vertical incision is made through the skin, subcutaneous tissues, and anterior rectus sheath 1 cm medial to the lateral border of the rectus muscle. The lateral flap of the anterior sheath is held forward and the rectus muscle retracted medially after having been freed by ligation and division of its vascular attachments. The intercostal nerve encountered is shown uncut. The posterior rectus sheath of the transversalis fascia and the peritoneum are incised.

sheath

Figure 21-36 The upper midabdominal transverse incision. A, Skin incision made and anterior rectus sheaths incised transversely. B, Rectus muscles transected and the incision completed. Note that the rectus muscles do not retract between the sheath.

Figure 21-36 The upper midabdominal transverse incision. A, Skin incision made and anterior rectus sheaths incised transversely. B, Rectus muscles transected and the incision completed. Note that the rectus muscles do not retract between the sheath.

Transverse Colon Recti Divarication

Figure 21-37 Modified upper abdominal transverse incision by retracting instead of severing the rectus muscles (R.L. Sanders). A, Incision through skin, subcutaneous tissues, and anterior rectus sheaths about 3 cm above the umbilicus. Band C, Anterior sheaths dissected from attachments to lineae transversae of rectus muscles and retracted. D, Lateral retraction of rectus muscles and transverse incision of the posterior sheaths and peritoneum. E, Division of the round ligament of the liver between clamps. F, Round ligament ligated; margins of incision retracted, exposing the adjacent abdominal viscera. G, Suture of the peritoneum and posterior rectus sheaths. H, Suture of the anterior rectus sheath. Interrupted sutures are preferred by many surgeons to approximate the cut edges of the anterior sheaths.

Figure 21-38 Incision for splenectomy. A, Skin incision. B, Anterior sheath of rectus muscle incised and the incision carried through fascia of the external oblique until muscle fibers are reached. Incised fascial margins are shown retracted, exposing the rectus and internal oblique muscles. C, Medial retraction of the rectus muscle preparatory to division of the posterior rectus sheath and entering the abdominal cavity. D, Lateral and downward continuation of the incision, splitting the fibers of the internal oblique and cutting across the fibers of the transversus abdominis and through the peritoneum. E through G, Progressive steps of closure of the fascial, muscular, and skin layers. (From Singleton, A.O.: Splenectomy. Surg. Gynecol. Obstet., 70:1051, 1940. By permission of Surgery, Gynecology and Obstetrics.)

Figure 21-39 A, Incision used for right colectomy. External and internal oblique muscles split in direction of their fibers. Left healed transverse scar used for ileotransverse colostomy. B, Transversalis muscle split in direction of its fibers and rectus muscle cross-cut in part or in whole, depending on exposure needed. (From Coller, F.A., and Vaughan, H.H.: Treatment of carcinoma of colon. Ann. Surg., 121:305, 1945,

Colostomy Healed Scars

Figure 21-40 Pfannenstiel incision. 1, Curved incision just above pubic hairline, extending beyond lateral borders of rectus muscles. Note that in this panel, the patient is oriented with the head at the bottom. 2, Fascial covering of recti incised. 3, Transversalis fascia and peritoneum incised between tissue forceps. Closure: 4 Approximation of median borders of rectus muscles with interrupted stitches. 6, Suture of anterior fascial defect. (From Parsons, L., and Ulfelder, H.: Atlas of Pelvic Operations. Philadelphia, W.B. Saunders, 1968, with permission.)

Suture of transversalis fascia and peritoneum approximating serosal surfaces of peritoneum. 5,

Serosa Fascia ColonSerosa Fascia Colon

Figure 21-43 Right or left lower quadrant transverse incision (combined abdominoperineal incision). A, Anterior rectus sheath incised transversely and external oblique fibers split. B, External oblique retracted. Rectus muscle transected. Internal oblique and transversus abdominis split clear to the pelvic wall. C, The incision completed. Note retraction of the iliohypogastric nerve.

Figure 21-43 Right or left lower quadrant transverse incision (combined abdominoperineal incision). A, Anterior rectus sheath incised transversely and external oblique fibers split. B, External oblique retracted. Rectus muscle transected. Internal oblique and transversus abdominis split clear to the pelvic wall. C, The incision completed. Note retraction of the iliohypogastric nerve.

Sheath Rectus Abdominis
Figure 21-45 Oblique incision. A, Rectus muscle transected over a finger inserted beneath it. B, Incision completed.
Figure 21-48 Kocher's lateral oblique incision, sometimes used for exploring the ascending colon in patients with carcinoma. (From Maingot, R.: Abdominal Operations, 2nd ed. New York, Appleton-Century-Crofts, 1948, with permission.)
Incisi Bevan
Figure 21-50 Bevan nerve-conserving incisions in the upper abdominal quadrants.

References

1. Ali, J., and Khan, T.A.: The comparative effects of muscle transection and median upper abdominal incisions on postoperative pulmonary function. Surg. Gynecol. Obstet., ¡48:863, 1979.

2. Becquemin, J.P., Piquet, J., Becquemin, M.H., et al.: Pulmonary function after transverse or midline incision in patients with obstructive pulmonary disease. Intens. Care Med., ¡¡:247, 1985.

3. Coller, F.A., and MacLean, K.F.: In Cole, W.H. (ed.): Operative Technic in General Surgery. New York, Appleton-Century-Crofts, 1949, p. 314.

4. Elman, A., Langonnet, F., Dixsaut, G., et al.: Respiratory function is impaired less by transverse than by median vertical supraumbilical incision. Intens. Care Med., 7:235, 1981.

5. Lampe, G.W.: Surgical anatomy of the abdominal wall. Surg. Clin. North Am., S2:545, 1952.

6. LeFevre, H.: La gastrectomie totale: Nouvelle technique operatiore. Résultats. Mém. Acad. Chir., Z2:580, 1946.

7. Miller, H.: Sternum-splitting incision for upper abdominal surgery. Arch. Surg., 65:876, 1952.

8. Rees, V.L., and Coller, F.A.: Anatomic and clinical study of the transverse abdominal incision. Arch. Surg., 47:136, 1943.

9. Saint, J.H., and Braslow, L.E.: Removal of the xiphoid process as an aid in operations on the upper abdomen. Surgery, SS:361, 1953.

10. Singleton, A.O.: Improvement in the management of upper abdominal operations, stressing an anatomical incision. South. Med. J., 24:200, 1931.

11. Sloan, G.A.: A new upper abdominal incision. Surg. Gynecol. Obstet., 45:678, 1927.

12. Williams, D.W., and Brenowitz, J.B.: Ventilatory patterns after vertical and transverse upper abdominal incisions. Am. J. Surg., ¡30.125, 1975.

Was this article helpful?

0 0
Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

Get My Free Ebook


Post a comment